CODING COrNer Coding and Compliance list.” just because a physician is a specialist, it does not mean all of their patient visits will qualify for a level 4 or 5 e&m level of care. It is important that you monitor and provide feedback to your clients on their e&m distribution levels so that you can both identify and address areas of concern. specialists will tend to bill more high-level e&m visits than nonspecialists, and that is fine if there is appropriate documentation and medical necessity to support the selected codes. I still remember being told years ago by an ob-gyn, “We bill all new patients as a level 4 and all established patients as a level 3.” The rationale behind this was simple: we do “x” number of things for the patient, therefore it warrants that level. It is essential that your clients understand what supports the various levels of care. When medicare ceased to pay a greater reimbursement for the e&m consultation codes, it eliminated many of the concerns around inappropriate billing practices for these codes. That said, it is important that you bill non-medicare payors and patients appropriately for these services and not automatically assign a high-level consultation code for each new patient. Here is the bottom line: make sure your clients use appropriate documentation to support the assigned e&m levels. RISK NUMBER 3: Automatically billing an E&M with a minor procedure Now for number five on the “Top 10” list. On two occasions over the last year, I have experienced working with two different specialists billing separate e&m visits in conjunction with a minor procedure when there was nothing to support a separate visit charge. There was no history, exam, medical decision making, counseling, or other modifying factor to justify a separate visit. The office staff in both instances explained that they “always bill a visit with that procedure.” so, clearly they have been instructed to always add a level 2 established patient visit (99212) to a minor procedure regardless of the circumstances or documentation. While I would never assume that every practice does this, it did make me think it is more prevalent than it should be. just because a provider sees a patient on the day of a minor procedure does not necessarily mean it is appropriate to bill an e&m service. e&m services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an e&m service. a minor procedure is one that has a zero-day or a ten-day global period. With regard to e&m services on the same day as a minor procedure, the Correct Coding Initiative (CCI) manual states the following: In general e&m services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an e&m service. However, a significant and separately identifiable e&m service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The e&m service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting e&m services apply. The fact that the patient is “new” to the provider is not sufficient Are You Following Us? join us on Facebook, Twitter, YouTube, and linkedIn. go to the HBma homepage to get connected. • Follow news and views • Find out what’s new with the association • Post comments about conferences, distance learning, or news • retweet HBma posts on Twitter • like, comment, and share HBma Facebook posts • like, comment, and share YouTube videos • Network with other members and colleagues • join discussions and ask questions www.hbma.org THe jOurNal OF THe HealTHCare BIllINg aND maNagemeNT assOCIaTION 35
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